The role of medical group insurance in the health care delivery system

Health care is a transforming industry; and understanding the health care landscape today is a daunting task for anyone. Doctors are no longer single decision makers when it comes to one’s health. If one is currently enrolled in, or considering joining Medicare Advantage Plan, it is important that they understand the role that medical group plays in the health care delivery system.

The network of physicians that delivers care is a very important element of the Managed Care model. That network can be administered by a health plan (such as the Kaiser Permanente model). It can also be created and managed by a third party, in which case it is called a medical group.

There are two main types of medical groups. One, also called a “staff model,” such as Scripps Clinic, is a large organization that employs doctors and other medical and non-medical providers. The other type, called IPA (Independent Physicians Association) like Mercy Physicians, is a management company that private doctors can join to have access to managed care.

In both cases, the medical group negotiates and executes contracts with HMO’s, provides training and education for doctors, conducts reporting to federal government, negotiates payments for medical services, and promotes doctors. The medical group is a “middle man” between doctors and health plans and a very important element of the health care delivery system.

The medical group has an impact on the quality of one’s health care since it determines the network of specialists and other providers available to the individual, as well as one’s everyday health care experience. It decides how quickly referrals are processed or what lab one uses as well.

Some doctors are affiliated with more than one IPA. If that is the case, it is important that the individual checks the network of specialists and other providers for each of them. The cardiologist who is extremely important to the patient may be part of one IPA, but not the other.

Medicare Advantage Plans don’t contract with doctors directly, but through the medical groups, so a specific MA-PD can have a doctor on the network but not necessarily with the right IPA.

A medical group is an element of the managed care system and is very interested in promotion of preventive care, a healthy lifestyle and an innovative approach to treatment, particularly when it comes to chronic diseases.

Most of the groups have a member services department, another value added service that helps members navigate the maze of modern health care as well as assisting both doctors and patients in using available services and programs to increase the effectiveness of medical treatment.

It is important that members of the Medicare Advantage Plan are aware of the benefits offered by their medical group.